The Westmead Pediatric TBI Multidisciplinary Outcome study: use of functional outcomes data to determine resource prioritization.

OBJECTIVE: To measure functional outcome in the 2 years after traumatic brain injury (TBI) in 2 groups of children and to determine the usefulness of a TBI severity classification system for resource allocation. DESIGN: Prospective inception cohort study with 3 assessment points during the 2 years after trauma. SETTING: Tertiary pediatric trauma center in Sydney, Australia. PARTICIPANTS: Eighty-one consecutive admissions aged 0 to 14 years. Fifty-one were allocated to the Mild (n = 26) or Severe (n = 25) TBI groups, according to preset determinants of severity; 30 admissions with non-TBI trauma constituted the control group. MAIN OUTCOME MEASURES: Standardized psychometric and clinical assessments of cognition, communication and feeding ability, motor performance (ambulation, fine and gross motor), neurologic status, self-care independence, and school/academic performance. RESULTS: Those with Mild TBI severity had no significant deficits at the 2-year data point. In contrast, those in the Severe TBI group demonstrated continued problems with fine motor performance, neurologic status, self care, and school/academic performance. CONCLUSIONS: A classification system has been developed that may be useful in the allocation of children with a TBI, age younger than 15 years, to 1 of 2 severity groups early in their rehabilitation. This classification system may be useful in determining areas of high and low resource prioritization.

The incidence of child sexual abuse in Northern Ireland.

This is part of a major epidemiological survey of the reported incidence (new cases) of child sexual abuse in Northern Ireland. Based on multi-source methodology, the study used computer-based record linkage techniques to find the number of incident cases occurring in the Province in 1987. Reporters involved with the incident cases were interviewed by OEV who recorded details of the child, the abuse, and the abuser using a specially designed questionnaire. Age-sex specific incidence rates adjusted for potential misclassification were computed and allowance made for under-ascertainment. Overall, 408 Established cases were reported during 1987. The corresponding incidence rate for Northern Ireland was 0.9 cases per 1000 children. When Suspected and Alleged cases were compared with Established cases, a further 119 cases were allocated by discriminant function analysis to the Established group, and the rate rose to 1.16 per thousand. Selected reporters were interviewed about ascertainment which was estimated to lie between 62% and 74%. If the lowest level of ascertainment applied the corresponding incidence rate for Northern Ireland would increase to 1.87. These figures are higher than those currently reported elsewhere in the UK, but methodological differences in study design hamper interregional comparisons. A number of relevant methodological problems are discussed.

Patient compliance with colorectal cancer screening in general practice.

A randomized controlled trial to test patient compliance with screening for colorectal cancer in association with general practice health checks was carried out in six practices (three urban and three rural). A total of 1588 patients aged 45-64 years were randomized to one of four intervention groups. In the first group patients were posted a Haemoccult test (Kline Beckman) kit. This group was not invited for a health check. In the second group patients were posted the Haemoccult test kit, together with an invitation to attend for a health check. In the third group patients were posted an invitation for a health check, which explained that the patient would be offered the Haemoccult test kit by the nurse at the health check. In the fourth group patients were just invited for a health check. It was found that combining faecal occult blood testing with the health check did not reduce attendance at the health check--43.5% of patients attended when the Haemoccult test kit was offered by the nurse at the health check, 43.6% attended when a test kit was included with the invitation to attend the health check and 42.9% attended when the health check invitation was posted on its own. Overall, compliance with Haemoccult testing was not significantly increased by associating it with a health check (26.2% versus 25.5%) but compliance was higher when the faecal occult blood testing kit was enclosed with the health check invitation than when it was offered at the health check (31.7% versus 20.6%, P less than 0.001). It is easier and cheaper to combine various screening procedures. Although the overall use of the Haemoccult test in the study population was low, there is no reason why the relatively higher compliance rate obtained on posting the test kit with a health check invitation cannot be achieved in previously unscreened populations with higher expected compliance rates. However, faecal occult blood screening for colorectal cancer should not be undertaken on a population basis until its effectiveness in reducing mortality has been proven by randomized trial.

Farmer's lung in Northern Ireland.

A total of 381 farmers in Northern Ireland were studied using a questionnaire, pulmonary function tests, and antibody levels to Micropolyspora faena to assess the incidence of farmer's lung. Twenty (4.9%) had a history of a previous diagnosis of farmer's lung by their doctor. Forty four (10.4%) had delayed onset symptoms compatible with farmer's lung, 32 (7.9%) had precipitant antibody, and 61 (15%) had raised antibody by the enzyme linked immunosorbent (ELISA) method. Restricted lungs were present physiologically in 40 (9.8%). A confirmation of delayed symptoms and precipitant antibody was present in seven (1.7%) whereas delayed symptoms and ELISA antibody was present in nine (2.2%). Using either antibody method only two (0.5%) had a combination of antibody to M faenae, delayed onset symptoms, and restricted pulmonary physiology.

Fatal ischaemic heart disease in Belfast: a comparison of two community surveys.

Data from two community surveys in Belfast were used to compare all deaths attributed to ischaemic heart disease during two one-year periods (1965/66 and 1981/82). There was an increase in mortality in men of all ages from 3.3 to 4.4 per 1,000 population (33%) and in women from 1.6 to 3.1 per 1,000 population (94%). Only in men aged less than 70 years was the mortality rate unchanged (2.2 per 1,000 population). The proportion of deaths in persons whose fatal attack began outside the hospital was virtually unchanged (65% in 1965/66 compared with 69% in 1981/82). Survival time was markedly decreased in the later survey, as were delay times in initiating medical care. The increase in mortality probably is due to an increase in the incidence of acute myocardial infarction. The introduction of mobile coronary care in Belfast in 1965 seems to have had equal effects in reducing mortality inside and outside hospital.

Respiratory disability in ex-flax workers.

Acute respiratory effects occur in a high proportion of subjects exposed to textile dusts. The extent to which these lead to permanent respiratory symptoms and loss of lung function is unknown. A survey of random population samples was therefore conducted in ten towns in Northern Ireland in which flax processing had been a major source of employment. The MRC questionnaire on respiratory symptoms was administered and Vitalograph tracings recorded on subjects aged 40 to 74 inclusive. An occupational history was taken at the end of each interview. Lung function in ex-flax workers was slightly lower than in control subjects never exposed to flax dust, but the presence of a positive interaction with age meant that differences were apparent only in the younger subjects. Over about the age of 65 the lung function in the ex-flax workers was comparable with that of the controls and overall the loss was at most about half that due to light smoking (1-14 cigarettes a day). The association between a "dust exposure score" and lung function was inconsistent in the two sexes. In men there was a small decrement with increasing dust exposure. In women there was also a small decrement, but a positive interaction with age meant that the women with the highest dust exposure scores had a lower loss with increasing age than the women with the least dust exposure. There was an excess in symptoms in the ex-flax workers but the size of the excess was greater than would be expected from the lung function results. It is possible that, although the survey was conducted without explicit reference to the flax industry, knowledge throughout Northern Ireland that many flax workers have been awarded compensation on the grounds of respiratory disablement may have led to an increased reporting of symptoms in the ex-flax workers.

Deaths from ischaemic heart disease in Belfast.

There were 1323 deaths due to ischaemic heart disease in Belfast from 20 July 1981 to 19 July 1982. Some 496 (37%) of these were in persons aged less than 70 years. By World Health Organisation criteria 247 (19%) of these deaths were classified as definite myocardial infarction and 749 (57%) as possible myocardial infarction. Dyspnoea, collapse, and typical pain were the main symptoms at the onset of the fatal attack. In hospital only 12% of deaths in persons aged less than 70 years and 14% of those aged greater than or equal to 70 years were due to presumed primary rhythm disturbance, whereas outside hospital these proportions were 78% and 59% respectively. The median survival time was 84 minutes and was shortest in men aged less than 70 years (62 minutes). Outside hospital a relative was the most likely aid sought initially (70%) and the median delay time from onset of symptoms to calling for medical aid was eight minutes. Among 128 witnessed deaths in persons aged less than 70 years occurring outside hospital due to presumed primary rhythm disturbance the median survival time was 8 X 25 minutes. Improvements in facilities available for resuscitation including public education could result in the prevention of a proportion of deaths caused by primary rhythm disturbances.

Certification of death from ischaemic heart disease in Belfast.

All death certificates over a one-year period (20 July 1981 to 19 July 1982) for residents of Belfast were examined in order to ascertain those due to ischaemic heart disease. Some 1654 were included for further investigation of which 1288 (78%) were coded by ICD Nos 410-414 (9th revision). Additional data were obtained from hospital records, ECGs, cardiac enzyme measurements, post mortems, general practitioners and from relatives of the deceased. Some 108 deaths coded by 410-414 and 223 deaths coded by other rubrics were eventually excluded. For people aged less than 70 years the net effect of excluding these deaths and including some coded under rubrics other than 410-414 was very small representing a change from 498 to 496 deaths (-0.4%). For people aged 70 years and above the net effect also was small, namely an increase from 790 to 827 (+4.4%). We conclude that the total number of deaths recorded as being due to IHD in Belfast was reasonably accurate. While 76% of deaths registered under ICD Nos 410-414 had been coded by ICD No 410 (acute myocardial infarction) only 19% of all deaths due to IHD could be classified as definite myocardial infarction using World Health Organization criteria.